STDs Flashcards
epidemiology
Single greatest risk factor for contracting an STD – number of sexual partners
Two-thirds of STD cases each year occur in persons in their teens and twenties
Rates for many STDs are higher in African-Americans and Hispanics
Rates are greater in “men who have sex with men” (MSM) than in heterosexuals for all major STDs
Marital status – more common in single, separated, and divorced persons
Higher rates of STDs in users of erectile dysfunction drugs (including HIV)
Congenital or neonatal infections – serious sequelae
-Acquired at birth – C. trachomatis, N. gonorrhoeae, herpes simplex virus
-Syphilis – transmitted transplacentally
-Ophthalmia neonatorum – results from chlamydia or gonorrheal infections
-Neurologic impairment – syphilis, herpes
Pregnancy – all pregnant women should be screened for chlamydia, HIV, syphilis, hepatitis B surface antigen, and hepatitis C antibodies at the first prenatal visit; screen for gonorrhea if women is at high risk (age ≤ 24 years old, previous gonococcal infection, new or multiple sex partners, inconsistent condom use, commercial sex work, drug use).
Gonorrhea etiologic agent
Neisseria gonorrhoeae
Gonorrhea epidemiology
gonorrhea rate in African-Americans was 10.6 times greater than whites in 2014
Highest rates in females 15-24 years old and men 20-29 years old
Risk factors: low socioeconomic status, urban residence, unmarried, previous history of gonorrheal infection
High incidence in prostitutes and IVDA
Associated with increased HIV transmission
Major cause of pelvic inflammatory disease
clinical manifestations of gonorrhea - genital infections in men
Predominant manifestation – acute urethritis
Symptoms – purulent urethral discharge and dysuria
If untreated, spontaneous resolution after several weeks
clinical manifestations of gonorrhea - uncomplicated genital infections in women
Primary site – endocervix
Up to 80% of women are asymptomatic or mildly symptomatic
Symptoms: cervicitis and/or urethritis → increased vaginal discharge, dysuria, urinary frequency, intermenstrual bleeding, menorrhagia
≈ 15% of women with gonorrhea develop PID
Disseminated gonorrhea infection may occur – more common in women
clinical manifestations of gonorrhea - anorectal infection
Most patients are asymptomatic
If symptomatic – acute proctitis → anal pruritis, tenesmus, purulent discharge, rectal bleeding/discharge, rectal pain
clinical manifestations of gonorrhea - pharyngeal infection
Major risk factor – orogenital sexual exposure
Most are asymptomatic; may cause pharyngitis or cervical lymphadenitis
Poor response to some treatments
clinical manifestations of gonorrhea - gonococcal infection in the newborn
Results from passage through the birth canal (may be transmitted in utero)
Most common form – ophthalmia neonatorum
If not treated properly → corneal ulceration and blindness
Gonnorhea diagnosis
Gram stain of a male urethral specimen – gram-negative diplococci within PMNs
Nucleic acid amplification tests (NAAT) – standard of care (urine or endocervical, vaginal, and urethral swabs)
Culture – endocervical or urethral swab
Gonorrhea treatment - potential efficacy of treatment of concurrent infections
Most common coexisting infection – genital chlamydial infection
15-25% of heterosexual men and 35-50% of women are also infected with C. trachomatis → concomitant treatment required***
Incubating syphilis – ceftriaxone is effective in eradicating GC and incubating syphilis
Gonorrhea treatment - concerns for resistant N. gonorrheae
Fluoroquinolones
-In 2015, 22.3% of isolates were resistant to ciprofloxacin
-FQNG more common in MSM (32.1% in 2015 compared to 16.4% in
MSW)
-CDC revised treatment guidelines in April 2007 and no longer recommends fluoroquinolones to treat any gonorrhea case in the United States
Cefixime
-In 2015, 0.5% of isolates had cefixime MICs ≥ 0.25 µg/ml
-CDC revised treatment guidelines in 2010 and no longer recommend cefixime as first-line therapy
Ceftriaxone
-In 2015, 0.3% of isolates had ceftriaxone MIC ≥ 0.125 µg/ml
Azithromycin
-In 2013-15, 2.6% of isolates had azithromycin MIC ≥ 2 µg/ml
treatment of uncomplicated gonococcal infections of the cervix, urethra and rectum***
1) Ceftriaxone 250 mg IM as a single dose PLUS Azithromycin 1 gram PO in a single dose OR doxycycline 100 mg PO BID for 7 days
2) Alternative if ceftriaxone is not available: Cefixime 400 mg PO in a single dose PLUS Azithromycin 1 gram PO in a single dose OR doxycycline 100 mg PO BID for 7 days PLUS Test-of-cure in 1 week
3) If patient has severe cephalosporin allergy: Spectinomycin 2 g IM x 1 PLUS Test-of-cure in 1 week
treatment of uncomplicated gonococcal infection of the pharynx***
Ceftriaxone 250 mg IM in a single dose PLUS Azithromycin 1 gram PO in a single dose OR doxycycline 100 mg PO BID for 7 days
Treatment of disseminated gonococcal infection**
Ceftriaxone 1 gram IM/IV q24h – recommended regimen
Cefotaxime 1 gram IV q8h
Ceftizoxime 1 gram IV q8h
Switch to cefixime 400 mg PO q12h after 24-48 hours of IV therapy to complete 1 week of therapy
treatment of gonorrhea during pregnancy**
Ceftriaxone 250 mg IM x 1 plus azithromycin 1 g PO x 1
Do not treat with tetracycline
Spectinomycin 2 grams IM x 1 if allergic
syphilis etiologic agent
Treponema pallidum (spirochete)
syphilis epidemiology
men 10x more than women
african americans > hispanics and whites
strong association between HIV and syphilis
primary syphilis
After exposure, a painless lesion (chancre) appears at the site of entry (≈ 3 weeks) → highly infectious
Chancre – usually single, dull red macule → papule that erodes and ulcerates; round or oval, indurated and well-marginated
Chancres disappear spontaneously without treatment (3-6 weeks)
secondary syphilis
Develops 2-6 weeks after onset of primary stage
Characterized by a variety of mucocutaneous eruptions → secondary to widespread hematogenous and lymphatic spread
Lesions – anywhere on body including palms of hands and soles of feet
Other symptoms – malaise, fever, pharyngitis, headache, anorexia, arthralgias, generalized lymphadenopathy
Signs disappear in 4-10 weeks
latent syphilis
Patients have positive serologic tests but no other evidence of disease
Divided into early latent and late latent stages
-Early latent – patient is potentially infectious; defined as 1 year from the onset of infections
-Late latent – patient is considered non-infectious (exception – pregnancy)
≈ 25-30% of patients progress to tertiary syphilis
tertiary (late) syphilis
Slowly progressing, inflammatory phase of the disease
Can affect any organ in the body
neurosyphilis
Headache, meningismus, increased CSF leukocyte count and protein
VDRL-CSF – when reactive, diagnostic for neurosyphilis
congenital syphilis
T. pallidum can cross placenta at any time
May result in fetal death, prematurity, or congenital syphilis
Early congenital syphilis – manifestations resemble secondary syphilis
diagnosis of syphilis - microscopic examination of material from lesion
Primary syphilis – presence of T. pallidum on dark-field microscopy
Secondary syphilis – spirochete may be found in cutaneous lesions and lymph nodes
Direct fluorescent antibody test (DFA-TP)
-Greater specificity than dark-field microscopy
-Does require exam of fresh specimen
-More labor intensive and expensive
diagnosis of syphilis - nontreponemal serologic testing
detect reagin (heterogeneous group of antibodies)
Commonly used tests – Venereal Disease Research Laboratory (VDRL); Rapid plasma reagin (RPR), unheated serum reagin test (USR); toluidine red unheated serum test (TRUST)
Positive test indicates presence of any stage of syphilis
Negative in incubating syphilis and early primary syphilis
Used primarily for screening; also useful in following progression of disease and response to therapy (repeat the same test by the same lab)
Seronegativity occurs in patients successfully treated primary and secondary syphilis; early latent – may take up to 4 years; late latent and tertiary syphilis remain seropositive for life
diagnosis of syphilis - treponemal serologic tests
more sensitive than nontreponemal tests; confirmatory
Fluorescent treponemal antibody absorption (FTA-ABS) test
-T. pallidum antigen used to detect antibodies to treponemal organisms
-Becomes positive earlier than nontreponemal tests
-Reactive for life after appropriate treatment of any syphilis stage
T. pallidum hemagglutination assay (TPHA)
T. pallidum passive particle agglutination (TP-PA)
EIAs
syphilis treatment
treatment of choice for all stages of syphilis
primary and secondary syphilis treatment
Benzathine penicillin G 2.4 million units IM x 1 dose
early latent syphilis treatment
less than 1 year duration
Benzathine penicillin 2.4 million units IM x 1 dose
late latent syphilis treatment
> 1 year duration or latent syphilis of unknown duration
Benzathine penicillin G 2.4 million units IM once weekly x 3 weeks
tertiary syphilis treatment
Benzathine penicillin G 2.4 million units IM once weekly x 3 weeks
neurosyphilis treatment
Aqueous crystalline** penicillin G 3-4 million units IV q4h x 10-14 days (or 18-24 million units per day as a continuous infusion) - NOT benzathine penicillin (will kill pt if given IV)
Alternative: procaine penicillin 2.4 million units IM QD plus probenecid 500 mg PO QID for 10-14 days
May administer benzathine penicillin 2.4 million units IM once weekly x 3 weeks after completion of IV therapy
Penicillin allergy – ceftriaxone 2 g IM or IV once daily for 10-14 days (? cross reactivity)
treatment of syphilis in patients with HIV
Primary and secondary syphilis
-Benzathine penicillin 2.4 million units IM x 1 dose
-If penicillin allergic – same as non-HIV infected patient
Early latent, late latent or syphilis of unknown duration
-Early latent - benzathine penicillin 2.4 million units IM x 1
-Late latent or unknown duration – benzathine penicillin 2.4 million units IM once weekly for 3 weeks
Neurosyphilis – same as non-HIV infected patient
treatment of syphilis in pregnant women
penicillin is only agent that reliable protects and treats the fetus; if penicillin allergic → skin testing → desensitization → treat with penicillin regimen appropriate for their stage of infection
Jarisch-Herxheimer reaction
Characterized by flu-like symptoms, headache, fever, chills, malaise, arthralgia, myalgia, tachycardia, peripheral vasodilation
Begins 2-4 hours after initiating syphilis therapy; may last 12-24 hours
Do not confuse with penicillin allergy
chlamydia etiologic agent
Chlamydia trachomatis
chlamydia epidemiology
females, AA
clinical presentation of chlamydia
Males
-Most common symptoms – dysuria, urinary frequency, mucoid urethral discharge (7-21 days after exposure)
-≈ 50% are asymptomatic
-Rectal infections occur in homosexual men; usually aymptomatic
Females
-Majority are asymptomatic; dysuria and frequency are uncommon
-If symptomatic – endocervicitis with a mucopurulent discharge
-Major cause of PID; increased risk of cervical dysplasia
Infants
-Transmitted via contact with cervicovaginal secretions (70%)
-Most common cause of neonatal eye infection and of afebrile interstitial pneumonia in infants less than 6 months old
chlamydia diagnosis
Nucleic acid amplification testing (NAAT) – detection of chlamydia antigen in urine – sensitivity and specificity 90-100%
Giemsa stain of cell scrapings from the endocervix or urethra
Direct immunofluorescence
Cell culture - ≈ 100% specific, but time-consuming and expensive
treatment of chlamydia
Azithromycin 1 gram PO as a single dose
Doxycycline 100 mg PO BID for 7 days
treament of chlamydia in pregnancy
azithromycin 1 gram PO as a single dose
clinical presentation of mycoplasma genitalium
same as C. trachomatis
diagnosis of mycoplasma genitalium
Slow growing organism (no cell wall) – takes up to 6 weeks for positive culture
Nucleic acid amplification testing (NAAT) – preferred (urine, urethral, vaginal, cervical swabs
treatment of mycoplasma genitalium
Doxycycline for 7 days – only 30% cure rate
Azithromycin 1 gram single dose – ≈85% cure rate (resistance emerges rapidly)
Azithromycin 500 mg x 1, then 250 mg daily x 4 days (may be better than single dose regimen unless initial pathogen is macrolide-resistant)
Moxifloxacin 400 mg daily for 10-14 days (if macrolide resistant)
genital herpes etiology and epidemiology
HSV2
highest among non-Hispanic black females and non-Hispanic black males
Increases risk of becoming infected with HIV – major role in heterosexual spread
clinical presentation of genital herpes
Up to 50% of HSV-2 infections are asymptomatic
Effect of herpes on neonates exposed during pregnancy – high mortality and significant morbidity
clinical presentation of primary infection of genital herpes
First-episode primary infections - characterized by a prolonged duration of symptoms
-Flu-like symptoms – fever, headache, malaise, myalgias
-Local symptoms – pustular or ulcerative lesions on external genitalia (painful), itching, vaginal or urethral discharge, inguinal adenopathy
First-episode nonprimary genital herpes
-Infection in patients who have clinical or serologic evidence of prior HSV (usually HSV-1) infection at another body site
-Milder than true primary infections
Recurrent infections
-≈ 50% of patients experience a prodrome prior to appearance of recurrent lesions
-Symptoms more severe in women and immunocompromised patients
diagnosis of genital herpes
Viral culture – preferred virologic test
-Sensitivity 80-90%; specificity 100% for 1st episode
-Low sensitivity in recurrent infection
-Expensive, time-consuming, false negatives if specimens improperly collected or transported
HSV PCR
Serologic tests – ELISA to detect antibodies to HSV (takes a few weeks)
treatment of genital herpes - first clinical episode of genital herpes
Acyclovir 400 mg PO TID for 7-10 days
Acyclovir 200 mg 5 times a day for 7-10 days
Famciclovir 250 mg PO TID for 7-10 days
Valacyclovir 1 g PO BID for 7-10 days
treatment of genital herpes for episodic recurrent infection
benefit if started in prodrome or within 1 day after onset of lesions
Acyclovir 400 mg PO TID for 5 days or 800 mg PO BID for 5 days or 800 mg PO TID for 2 days
Famciclovir 125 mg PO BID for 5 days or 1 g PO BID for 1 day
Valacyclovir 500 mg PO BID for 3 days or 1 g QD for 5 days
treatment of genital herpes - regimens for daily suppressive therapy
Reduces frequency of recurrences by 70-80% in patients who have frequent recurrences (≥ 6/year)
Acyclovir 400 mg PO BID
Famciclovir 250 mg PO BID
Valacylovir 500 mg PO QD or 1 g PO QD
Valacyclovir 500 mg QD appears less effective than other regimens in patients who have very frequent recurrences (≥ 10/year)
treatment of genital herpes in severe disease
acyclovir 5-10 mg/kg/dose IV q8h for 2-7 days or until clinical improvement is observed, followed by oral therapy to complete at least 10 days.
treatment of gential herpes in patients with HIV
Regimens for episodic infections -Acyclovir 400 mg PO TID for 5-10 days -Famciclovir 500 mg PO BID for 5-10 days -Valacyclovir 1 g PO BID for 5-10 days Regimens for daily suppressive therapy -Acyclovir 400-800 mg PO BID to TID -Famciclovir 500 mg PO BID -Valacyclovir 500 mg PO BID
treatment of genital herpes if acyclovir resistant
foscarnet 40-80 mg/kg/dose IV q8h or cidofovir 5 mg/kg IV once weekly
trichomoniasis etiologic agent
Trichomonas vaginalis (flagellated, motile protozoan)
clinical presentation of trichomoniasis
Women
-Asymptomatic in up to 50%
-Symptoms (non-specific)
—Vaginal discharge (malodorous, foamy, greenish-yellow)
—Vulvar pruritis
—Dysuria
—Symptoms may worsen during menstruation
-Examine for other STDs – 3x risk of having gonorrhea
Men
-Majority are asymptomatic
-Symptoms – urethral discharge, pruritis, dysuria
-Trichomoniasis – a cause of treatment failure in patients with presumed NGU treated with tetracyclines or erythromycin
-Examine for other STDs – 20% of men with gonococcal urethritis have trichomoniasis
diagnosis of trichomoniasis
Wet mount examination of the discharge – characteristic pear-shaped, flagellating organisms (50-65% sensitive)
NAAT
Culture – highly specific and more sensitive than wet mount; takes 48 hours
treatment of trichomoniasis
Metronidazole 2 g PO in a single dose
Tinidazole 2 g PO in a single dose
Metronidazole 500 mg BID for 7 days (more effective in men than single dose)
Avoid alcohol with metronidazole (24 hours) and tinidazole (72 hours)
Treat the sexual partner
Metronidazole gel is much less effective than oral metronidazole
PID
Spectrum of inflammatory disorders of the upper female genital tract, including any combination of endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis
PID etiologic agents
N. gonorrhoeae C. trachomatis Vaginal flora (anaerobes, Gardnerella vaginalis, gram-negative bacilli, S. agalactiae) Mycoplasma hominis Ureaplasma urealyticum
PID sxs and diagnosis
Pelvic or lower abdominal pain Dyspareunia Adnexal tenderness Cervical motion tenderness Temperature > 101°F Abnormal cervical or vaginal discharge Laboratory documentation of N. gonorrhoeae or C. trachomatis
treatment of PID
**Cefotetan 2 g q12h OR cefoxitin 2 g IV q6h PLUS Doxycycline 100 mg IV or PO q12h
**Clindamycin 900 mg IV q8h PLUS Gentamicin 2 mg/kg loading dose, then 1.5 mg/kg q8h (single daily dose of 3-5 mg/kg may be substituted)
Alternative parenteral regimen: Ampicillin/sulbactam 3 g IV q6h PLUS Doxycycline 100 mg IV/PO q12h
IM/Orally-Based Treatment Regimens: Ceftriaxone 250 mg IM x 1 PLUS Doxycycline 100 mg PO q12h for 14 days WITH OR WITHOUT Metronidazole 500 mg PO q12h for 14 days
HPV epidemiology
Subclinical infection – untreatable; can lead to cervical, penile, anal cancer
- Persistent cervical infection with high risk HPV types is the most important risk factor for cervical neoplasia
- HPV types 6 and 11 can cause genital warts (account for 90% of genital warts)
- HPV types 16, 18, 31, 33, and 35 are strongly associated with cervical neoplasias (16 and 18 account for 70% of cervical cancers)
patient applied treatment of anogenital warts d/t HPV
Podofilox 0.5% solution or gel – apply BID for 3 days, followed by 4 days of no therapy; repeat for up to 4 cycles
Imiquimod 3.75-5% cream – apply once HS, every night for 3.75% and 3 times/week for 5%, for up to 16 weeks; treatment area should be washed with soap and H2O 6-10 hours after application
Sinecatechins 15% ointment – apply TID for no longer than 16 weeks; do not wash off after application
provider applied treatment of anogenital warts d/t HPV
Cryotherapy with liquid nitrogen or cryoprobe
Surgical removal
Trichloroacetic acid or bichloroacetic acid 80-90% solution
Vacciation of HPV
Gardasil, Gardasil-9, Cervarix
Vaccination is not recommended in women who are pregnant or trying to become pregnant
Sexually active women starting vaccination series should use contraception until series completed
If pregnancy occurs during vaccination series, delay dosing until end of pregnancy (pregnancy and outcome of pregnancy should be reported to the vaccine manufacturer’s registry)
Breastfeeding is permitted during vaccination series
